Time for a Change-Health Assessment!

LET'S START WITH YOU
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Age*
Height*
Weight*
Goal Weight*
WHERE ARE YOU RIGHT NOW?

And Why It's Time for a Change.
What made you say "I need to do something" about your health?*
Was it the mirror? The scale? Feeling tired all the time? A wake-up call from your doctor?
What's your biggest frustration when it comes to your health, energy, or weight?*
What have you struggled with? Where do you feel stuck?
What's something you've tried before that didn't work for you? Why do you think it didn't work?*
The average American spends $20-25/day on food. How much do you spend?*
How do you feel about where your health is at right now? (Pick One)*

I'm just getting by, but I know I could feel way better.I feel stuck and frustrated -- I need real change.I'm overwhelmed and don't know where to start.I feel decent, but I want to be at my best.Other
Do any of the following apply to you? (Select all that apply)

Gluten intolerance/allergyCeliacHigh Blood PressureThyroidCoumadin (warfarin)Type 1 DiabetesType 2 DiabetesFood allergyGoutGLP-1Medication/Shots (Wegovy/Ozempic/Mounjaro/Etc...)Other
WHERE DO YOU WANT TO BE?

And how we get you there.
If I could wave a magic wand and fast-forward 3 months from now... what would success look like for you?*
Be specific - how do you want to feel, look, move, and live?
What would change in your life if you hit your goal?*
More energy for your kids or grand kids? Confidence in your clothes? Feeling strong and in control again?
Why does this matter to you?*
This is big - Dig deep! What's the deeper reason you want this change?
Is there anyone you would like to get healthy with you? If so, who would it be?
What do you do for meals currently? (Eat out, Dine in, Cook, Other)
How did you hear about our program? (If you were referred by someone let us know who it was)
Are you a water drinker? If so, how much do you drink in a day?
What else do you drink regularly?
LET'S TALK ABOUT WHAT'S NEXT

The biggest mistake people make? Trying to figure it all out alone. You don’t have to. We've helped lots of people like you get results - without guessing, without overwhelm, and without wasting time on things that don’t work.
NEXT STEPS

✅ Fill this out and hit submit.
✅ We'll personally review your form and text you to set up a call.
✅ On the call, we'll map out a simple, realistic plan that fits YOUR life.

🚀 NOTHING CHANGES IF NOTHING CHANGES🚀
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LET'S START WITH YOU

WHERE ARE YOU RIGHT NOW?

WHERE DO YOU WANT TO BE?

LET'S TALK ABOUT WHAT'S NEXT